Protein & Nutrition Provision to Critically Ill Patients

Case Study in Colorectal Surgery

Kiki Lukman
Department of Surgery,
Medical Faculty of Universitas Padjadjaran
Dr Hasan Sadikin Hospital
Bandung

ACUTE CARE SURGERY, 2020 , BANDUNG 1

 OBJECTIVES

1. Describe the importance of protein provision as a means to

provide optimal nutritional support to ICU patients

2. Discuss the role of protein nutrition in ICU patients

ACUTE CARE SURGERY, 2020 , BANDUNG

 PATIENT

Physical examinations:
• 62-year old female
• Weight: 42 kg
• Acute peritonitis • Height: 155 cm
• Had chronic atrial fibrillation; • BMI: 17.5
stopped taking warfarin for 2
Healthy weight:
months due to bleeding
• 52 kgs
hemorrhoids
• Lost 10 kgs since husbands death in car
• Losing weight for last 7 accident
months (10 kgs total) Diagnosis for weight loss:
• Post traumatic depression

3
 PATIENT

IMAGING STUDY

Abdominal CT
• Dilated small bowel loops with
thin walls.
• Final diagnosis: small bowel
ischemia in part of the
jejunum and ileum.

4
 PATIENT

SURGICAL TREATMENT
LAPAROTOMY
• Sixty cm of the terminal jejunum and 60 cm of the ileum was
resected and primary end to end anastomosis was performed

Post Op Care
• Admitted to the ICU
• Hemodynamically unstable, receiving norepinephrine
0,5mcg/Kg/min to maintain blood-pressure
• Sedated with propofol and fentanyl, intubated and
under mechanical ventilation, but respiratory function was
normal
• Nasogastric tube for gastric drainage, and an IV double lumen
central line inserted

5
 PATIENT

Post Operative Care What seems to be the problem?

Lab Test Results • SEPSIS : Hypercatabolic state
• RISK FACTOR: CARDIAC ARRYTHMIA
• Metabolic acidosis • Pre existing malnutrition
• Plasma lactate: 29 mg/dl • Risk of short bowel syndrome
• Normal electrolytes and renal function
• Glucose: 250 mg/dl Is this PATIENT at nutritional risk?
• Risk of acute malnutrition superimpose pre
existing malnutrition
Next step ?:
Surgeons planned to perform a second look laparotomy within 72 hours.

6
 Nutritional Risk Screening (NRS 2002)
SEVERITY OF DISEASE
IMPAIRED NUTRITIONAL STATUS
(≈ Increase in Requirements)
Absent Normal nutritional status Absent Normal nutritional requirements
Score 0 Score 0
Hip fracture* Chronic patients, in
Wt loss > 5% in 3 mths or Food particular with acute
Mild intake below 50-75% of normal Mild complications: cirrhosis*, COPD*.
Score 1
requirement in preceding wk
Score 1
Chronic hemodialysis, diabetes, Is it the right
oncology
Wt loss > 5% in 2 mths or BMI
moment
*indicates that ato
trialstart a
directly supports the
Major abdominal surgery* Stroke*
Moderate
Score 2
18.5-20.5 + impaired general
condition or Food intake 25-60% of
Moderate
Score 2
X Severe pneumonia, hematologic nutritional
categorization of patients
with that diagnosis.
malignancy
normal requirement in preceding wk intervention?
Wt loss > 5% in 1 mth (>15% in
3 mths) or BMI <18.5 + impaired Head injury* Bone marrow
Severe general condition or Food intake Severe transplantation* Intensive care ABSOLUTELY NOT !
Score 3 X Score 3
0-25% of normal requirement in patients (APACHE >10)
preceding wk
Score: + Score: = Total Score:
3 2 5
Age: If ≥70 years: add 1 to total score above Age-adjusted Total Score:
Score ≥ 3: The patient is nutritionally at risk and a nutritional care plan is initiated.
Score < 3: Weekly rescreening of the patient. If patient e.g. is scheduled for a major operation, a preventive nutritional care plan is
considered to avoid the associated risk status.
Kondrup J, et al. Clin Nutr 2003;22:415-21
7
 24 Hours Later…

• Patient was hemodynamically stable

• Receiving norepinephrine 0.2 mcg/Kg/min
Is it the right time
• Blood gases and pH were normalized as well as blood lactate
• towas
Blood glucose start Nutrition Therapy?
220 mg/dl
• She was extubated and breathing spontaneously -respiratory and renal
functions remained normal
YES !
• Gastric output by nasogastric tube was 800ml in the last 24 hours
• There were no bowel sounds or movements. 

8
 The Primary Goal in Nutrition Support Therapy

Nitrogen/Protein
Essential and non-essential
amino acids

Energy
Carbohydrates (glucose) and lipids
(and essential fatty acids)
Primary
Goal Water, Vitamins,
and Minerals

Improve Clinical
Outcome

Bistrian BR, Hoffer L, Driscoll DF. Enteral and Parenteral Nutrition Therapy. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo
J. eds. Harrison's Principles of Internal Medicine, 19e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com/content.aspx?
bookid=1130&sectionid=63653665.Accessed March 30, 2017.

9
 NITROGEN BALANCE
Negative nitrogen balance occurs when…
Protein breakdown and amino acid oxidation increase
while synthesis remains unchanged
OR
Protein breakdown and amino acid oxidation remain
unchanged while synthesis decreases

1g of nitrogen is the equivalent of 30g of hydrated lean tissue.

Kinney JM, et al. J Clin Pathol Suppl (R Coll Pathol) 1970;4:65–72.

Ward N. Nutr J. 2003;2:18.
Schricker T, et al. J Appl Physiol. 2001;91:2523–2530.

10
Protein Catabolism Is the Hallmark of Critical Illness
THE MOST COMMON METHOD
FOR ASSESSING PROTEIN REQUIREMENTS IS
DETERMINATION OF
NITROGEN BALANCE

Determination of nitrogen balance can be used to assess protein turnover and

thereby protein requirements of a patient.

Improvement in nitrogen balance is the single nutritional

parameter most consistently associated with improved
outcomes during critical illness.
Manning EM, Shenkin A. Crit Care Clin. 1995;11:603–634.
11 Millward DJ. Proc Nutr Soc. 2012;71:566–565.
 Resting Metabolism and Nitrogen Excretion
Vary According to Type and Severity of Stress

Resting metabolism determined by indirect calorimetry and protein need by urinary nitrogen excretion.

180 Major burn

metabolism (%)
≈1.8-fold increase
160
Resting

Peritonitis
140
Fracture
120
100 NORMAL RANGE
Elective surgery
Nitrogen excretion

–12 Severe
sepsis
–16
(g/day)

Skeletal trauma
–20
–24
Major burn
–28 ≈3.0-fold increase
0 10 20 30 40 50 60 70 Days

Figure modified from Long CL, et al. JPEN J Parenter Enteral Nutr. 1979;3:452–6.
12
 Patients with Sepsis Show an Accelerated
Release of Amino Acids from Skeletal Muscle

• An increased level of amino acids is released from skeletal muscle and taken up by the liver and other
visceral tissues
– Sufficient amino acids are available to synthesize proteins for immunologic defense and healing

SEPSIS

Skeletal Muscle

Amino acid uptake  Amino acid uptake

Protein synthesis  Protein synthesis 
Protein breakdown  Acute phase protein synthesis 

13 Rosenblatt S, et al. Arch Surg. 1983;118:167–75.

 Protein Nutrition Goals May Not Be Achieved
in ICU Patients

M e a n P ro te in ( g / k g / d a y )
Observational cohort study (n=2772).

1.6

1.2

0.8

0.4

0.0
<20 20 to <25 25 to <30 30 to <35 35 to <40 ≥40
Body Mass Index

• Over 12 days, 69.0% received EN only, 8.0% received PN only, and 17.6% received EN plus PN.
• Overall, patients received only 50–65% of protein prescribed.
EN=enteral nutrition; PN=parenteral nutrition.

14 Calculated from Alberda C, et al. Intensive Care Med. 2009;35:1728-37.

 Early Feeding is Associated with Lower Mortality

Hospital
Hospital mortality
mortality for
for cumulative
cumulative energy
energy deficit
deficit over
over the
the first
first 44 days
days of
of ICU
ICU stay
stay for
for non-septic
non-septic
critically
critically ill
ill patients
patients (n=726;
(n=726; P=0.053)
P=0.053)
Mortality (%)
P=0.012

50
45
40
35
30
25 LOWEST
20 MORTALITY
15
10
5
0
>20% 10–20% 0–10% No Energy Deficit
(n=509) (n=83) (n=72) (n=62)

Energy Deficit

Reference is the measured resting energy expenditure of the patient.

Weijs PJM, et al. Crit Care. 2014;18(6):701.

15
 Early High Protein Intake Is Associated
With Low Mortality in Non-septic ICU Patients
Early
Early high-protein
high-protein intake
intake (≥1.2
(≥1.2 g/kg/day)
g/kg/day) at
at day
day 44 of
of ICU
ICU admission
admission was
was associated
associated with
with an
an approximately
approximately 45%
45% lower
lower
mortality
mortality rate
rate in
in non-septic,
non-septic, non-overfed,
non-overfed, mechanically
mechanically ventilated,
ventilated, critically
critically ill
ill adult
adult patients
patients
All Septic and Non-septic Patients Non-septic, Non-overfed Critically Ill Patients
Mortality (%)

P=0.008
P=0.047
40
35 38 37
35 35 35 35
30
25 27
20
19
15 45%
10 LOWER
MORTALITY
5
0
<0.8 0.8–1.0 1.0–1.2 >1.2
Protein Intake Group (g/kg)
Weijs PJM, et al. Crit Care. 2014;18(6):701.

16
ROUTE OF ADMINISTRATION?

• What would you choose?

Enteral Nutrition or Parenteral Nutrition?

17
 Enteral or Parenteral Nutrition?

ANSWER – Parenteral Nutrition

WHY?
• High output by gastric tube What are the patient’s
• Small bowel wide resection nutritional needs?
• Small bowel perfusion???
• A second look within 72 hours
• High risk of diarrhea
• Malnutrition

Vanderhoof JA. Gastroenterology. 1997;113(5):1767-78.

Keller J et al. Best Pract Res Clin Gastroenterol. 2004;18(5):977-92.

18
 Daily Nutritional Needs of Patient

• 20-25 Kcal/Kg/day (pocket formula)

• 1.5g/Kg/day of protein  1,050 Kcal

63g of protein
• ACTUAL WEIGHT: 42 KG

McClave SA, et al. JPEN J Parenter Enteral Nutr. 2009;33(3):277-316.

Singer P, et al. Clin Nutr. 2009;28(4):387-400.
Allingstrup MJ, et al. Clin Nutr. 2012;31(4):462-8.
Hoffer LJ. Am J Clin Nutr. 2003;78(5):906-11.

19
WHAT KIND OF TPN?

Would you choose a 3-in-1 bag?

(Glucose + Lipids + Proteins) 

Yes!

20
 3-in-1 bag?

Energy requirements Energy source

Amino acid Fat

Glucose

Why Lipids?   Mizock BA. Am J Med. 1995;98(1):75-84.

21
 Why Lipids?

Blood Glucose Essential Fatty

Control Acids

Critically ill patients oxidize simultaneously fat, carbohydrate

and protein as energy sources.

1. Schneider SM. Mediterr J Nutr Metab 2011;4:87–91.

2. Wanten G et al. Am J Clin Nutr. 2007;85:1171–84.

22
 Compounding a PN Solution
Example:

PROTEIN CONTENT: 42 Kg X 1.5g = 63g (10g of N) 252 kcal (4kcal/g)

- AA10% 630mL 252 kcal
FAT CONTENT: 42Kg X 1.0g = 42g of lipid
- Lipid emulsion (20%) 210ml 420 kcal

CARB CONTENT: 378 cal (left)

222mL of 50% Glucose solution
(3.4 Kcal/g of glucose 111g)

AA (10%) 630ml 252kcal

Lipid emulsion (20%) 210ml 420kcal
Glucose (50%) 222ml 378kcal
1.062ml 1,050 kcal
Plus electrolytes: Na, K, Ca, P and Mg
Plus micronutrients: vitamins and trace elements

1.Braga M, et al. Clin Nutr 2009;28:378-86.

23 2.Vanek VW, et al. Nutr Clin Pract 2012;27:440-91.
 OLIMEL NSE 1000 ml

• Each bag of OLIMEL N9E 1000 mL contains

solution:
– Glukose + Calsium 400 mL
– Lipid emulsion :200 mL
– Amino Acid + electrolytes : 400 mL
• Total calorie : OLIMEL N9E  1070 Kkal
• Osmolarity  1310 mOsm/L
COMPOSITION

WHY?
 ICU Patients Have Higher Protein Requirements1

PN protein intake guidelines recommendations of

1.3-1.5 g/kg (ESPEN)2 and 1.2-2.0 g/kg (ASPEN)3 in ICU patients
(vs standard 0.8 g/kg) was associated with1:
• Greater handgrip strength
• Greater muscle thickness on ultrasound
• Reduced Chalder fatigue score

1. Ferrie S, et al. JPEN J Parenter Enteral Nutr. 2016;40(6):795-805; 2. Singer P, et al. Clin Nutr. 2009;28:387–400;; 3. McClave
SA et al. JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.

26
 Does Energy/Nitrogen Ratio Vary
According to Patient Type?
400

Healthy TPL Cohorts of fed subjects

350
(<0.8 g/kg/day) Cohorts of fasting subjects
Cohorts of an undefined state
300 Energy/Nitrogen
E/N Ratio

Ratios
Moderate TPL Differ Significantly
250
According to Protein
(0.8 to <1.2 g/kg/day) Loss
200

150 High TPL

(≥1.2 g/kg/day)
100

50
0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2

Total Protein Loss (g/kg BW/day) E/N=energy/nitrogen; TPL=total protein loss.

Adapted from Kreymann G, et al. Clin Nutr. 2012;31:168–75.
27
 Most ICU Patients Receive Suboptimal
Protein Nutritiona
• Most common recommendation was 1.5 g protein/kg/day
– ICU patients mostly receive less than half this amount
for the first week or longer
• Nitrogen balance improved with increased protein provision up to highest dose
studied (2.5 g protein/kg/day)
• The authors concluded that 2.0–2.5 g protein/kg/day is safe and could be
optimal for most critically ill patients

A systematic review of MEDLINE-listed clinical trials, 1948 to 2012 to determine what was the
a.

optimal amount of protein (or amino acids) for ICU patients; 13 prospective and one retrospective
study identified.

Hoffer LJ, Bistrian BR. Am J Clin Nutr. 2012;96:591–600.

ICU, intensive care unit

28
 Protein Nutrition for Critically Ill Patients:
ASPEN, ESPEN Guidelines vs. MEDLINE Review

Protein Intake
Observations
(g/kg/day)
+0.2 g/kg/day or protein in trauma, obesity, or nephron-
ESPEN1 1.3–1.5 IBW replacement therapy patients
For high risk or severely malnourished patients and it may be
1.2–2.0 ABW
even higher in burn or multitrauma patients
If BMI 30–40 kg/m2 . IBW calculations is recommended for
ASPEN2 ≥2.0 IBW adult obese and critically ill patients.
If BMI ≥40 kg/m2. IBW calculations is recommended for adult
Up to 2.5 IBW obese and critically ill patients.
MEDLINE 1.5 IBW Most common recommendation
Clinical Trials
Review,
1948 to 20123 2.0–2.5 IBW May be safe and optimal for most critically ill patients

ESPEN=European Society for Parenteral and Enteral Nutrition; ASPEN=American Society of Parenteral and Enteral Nutrition;
SCCM=Society of Critical Care Medicine; BMI=body mass index; ABW=actual body weight; IBW=ideal body weight.
1. Singer P, et al. Clin Nutr. 2009;28:387–400; 2. McClave SA et al. JPEN J Parenter Enteral Nutr.
2016;40(2):159-211; 3. Hoffer LJ, Bistrian BR. Am29 J Clin Nutr. 2012;96:591–600.
 Patients Need Both Protein and Energy
High Nitrogen Demand
Condition
Intensive care1
Surgery2
Severe acute pancreatitis3
Acute renal failure (CRRT, severe
catabolism)4
Non-surgical oncology5
Acute renal failure (extracorporeal
therapy, moderate catabolism)4
Short bowel (post-operative)6
PN=parenteral nutrition; IBW=ideal body weight
Moderate Nitrogen Demand
Protein (Amino Acids)
1.3-1.5 g/kg IBW/day
1.5 g/kg IBW/day (in illness/
stressed conditions)
1.2-1.5 g/kg/day
Up to 1.7 g/kg/day
Minimum 1 g/kg/day to a
target of 1.3-2.0 g/kg/day
1.0-1.5 g/kg/day
1.0-1.5 g/kg/day
Energy
25 kcal/kg/day increasing to target
25 kcal/kg IBW/day up to 30 kcal/kg
IBW/day in conditions of severe stress 1. Singer P et al. Clin Nutr. 2009;28:387-
400; 2. Braga M et al. Clin Nutr.
2009;28:378-386; 3. Gianotti L et al. Clin
25-max. 30 kcal/kg IBW/day Nutr. 2009;28:428-435; 4. Cano NJM et al.
Clin Nutr. 2009;28:401-414; 5. Bozzetti F et
al. Clin Nutr. 2009;28:445-454; 6. Van
20-30 non-protein kcal/kg/day Gossum A et al. Clin Nutr. 2009;28:415-427;
7. http://espen.org. Accessed 8 November
2011.
20-25 kcal/kg/day (bedridden)
25-30 kcal/kg/day (ambulatory)
20-30 non-protein kcal/kg/day
25=33 kcal/kg/day
30
 Improved 10-Day Survival Rate in Higher Protein + AA
Groups Compared With Low Protein + AA Group

28-day survival in ICU

100%

Group 3: 88% survival*

High protein + AA
80% (average 1.46 g/kg,
% Survival

114.9 g/day; n=38)

Group 2: 79% survival*

60% Medium protein + AA
(average 1.06 g/kg, 84.3
g/day; n=38)

40% Group 1: 49% survival*

Low protein + AA,
(average 0.79 g/kg, 53.8
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 g/day; n=37)
Length of Stay in ICU (Days)
*Kaplan-Meier 10-day survival probability. AA=amino acids; ICU=intensive care unit.

Allingstrup MJ, et al. Clin Nutr. 2012;31:462–468. 31

Protein Nutrition Support in SARCOPENIC obese
ICU Patients

32
 What Is Sarcopenia?

Sarcopenia1,2
The progressive decline in skeletal
muscle mass leading to decreased
strength and functionality
• Associated with increased mortality
• Associated with aging
• May occur with chronic diseases and malignancy, resulting in
decreased functional capacity and higher risk of mortality

Sarcopenia and anabolic resistance can hinder protein anabolism1,3

1. Cruz-Jentoft AJ, et al. Age Ageing. 2010;39:412–23; 2. Montano-Loza AJ, et al. Clin Gastroenterol Hepatol.
2012;10:166–73, 73 e1.; 3. Dardevet D, et al. ScientificWorldJournal. 2012;2012(269531. Image accessed from
http://www.articlesweb.org/blog/wp-content/uploads/sites/1/nggallery/muscle-loss-5/Muscle-Loss-11.jpg

33
 Proposed Risk Factors of Sarcopenia

Anabolic
Inactivit resistance Anti-oxidants and phase 2
Anti- protein inducers
y inflammatory
Inflammatio
n Acid buffering
Relative Muscle Loss

Acidosi
s
Vit D
deficiency?
Age-related sarcopenia
Chronic conditions of muscle loss
(e.g. renal failure, heart failure, COPD, rheumatoid arthritis)
Acute, rapid wasting disorders
(e.g. sepsis, AIDS-HIV wasting, cancer cachexia)

1 10 100 1000 10000

Time (days)
Thick arrows indicate big effect
COPD = chronic obstructive pulmonary disease.
Adapted from Millward DJ. Proc Nutr Soc. 2012;71:566–75.

34
 Sarcopenia as Potential Predictor for Mortality
in Elderly ICU Patients (N=149)a

• Low muscle mass associated with:

Mortality (%)
35 32%
– Increased mortality (p=0.025) 30
– Decreased ventilator/ICU-free p=0.018
25
days (p=0.004 and p=0.002,
respectively) 20
• BMI, albumin, total adipose tissue or 14%
15
visceral adipose tissue on admission
did not predict survival, ventilator- 10
free or ICU-free days
5

0
BMI=body mass index; ICU=intensive care unit; CT=computed tomography Sarcopenic Non-sarcopenic
a
Aged >65 years with an abdominal CT scan; 71% were sarcopenic.
Muscle cross-sectional area was related to clinical parameters including ventilator-free days,
ICU-free days, and mortality.
Adapted from Moisey L, et al. Clinical Nutrition. Week 2013, Phoenix, AZ, USA. Abstract 1519390.

35
 High Protein Nutrition Supporta
Is Beneficial for Obese ICU Patients1-3

Achievement
of Positive Nitrogen
Balance

Better Preservation
Metabolic Equilibrium Hypocaloricb,
of Lean Body Mass
High
Protein
Nutritional
Support
Loss of Better Glycemic
Adipose Tissue Control
Improved Clinical
Outcome

Defined as 881 kcal/day, 2.13±0.59 g/kg protein in a study by Raza et al.1

a

ASPEN guidelines recommend hypocaloric PN feeding strategy of ≤20 kcal/kg/day or 80% of estimated energy needs for high risk or severely
b

malnourished patients but provides adequate protein (≥1.2 g protein/kg/d).2

1. Raza N, et al. Crit Care Clin. 2010;26:671–8; 2. McClave SA et al. JPEN J Parenter Enteral Nutr. 2016;40(2): 159-211; 3. Mesejo A, et al. Nutr Hosp.
2011;26(Suppl 2):54–8. 36
 Higher Protein Needs for Obese ICU Patients
Despite Increased BMI

Guidelines Energy Target Protein Target Observations

In the absence of IC:
11-14 kcal/kg ABW/day
ASPEN1 for BMI 30-50
22–25 kcal/kg IBW/day
for BMI >50
(g/kg/d of IBW)
≥2.0 for BMI of 30–<40
2.5 g for BMI of ≥40
Use of BMI and IBW
is recommended for
these calculations,
while use of ABW
should be avoided.

In the absence of IC: No recommendations

25 kcal/kg/day 1.3–1.5 g/kg IBW/day are specified for obese
ESPEN2 increasing with an adequate energy patients. Pre-
to target over the next supply (when PN is admission body weight
2–3 days indicated) may be used to
estimate IBW.3

ABW=Actual Body Weight; IBW=ideal body weight; ICU=intensive care unit; PN=parenteral nutrition; IC=Indirect
calorimetry.
1. McClave SA et al. JPEN J Parenter Enteral Nutr. 2016;40(2):159-211; 2. Singer P, et al.Clin Nutr 2009;28:387–400;
3. Weijs PJ, et al. Clin Nutr 2012;31:774–5.

37
What is the most threatening
complication related to TPN in
this patient?

Refeeding Syndrome (RFS)

38
 Refeeding Syndrome

• Occurs after the reintroduction of feeding after a period of starvation or fasting

• A series of metabolic and biochemical changes that occur as a consequence of
reintroduction of feeding after a period of:

Starvation
Starvation or Fasting
Fasting

Khan LU et al. Gastroenterol Res Pract. 2011;2011. pii: 410971. doi: 10.1155/2011/410971.

39
 CLINICAL MANIFESTATIONS OF REFEEDING
SYNDROME

• Symptoms of RFS are: CLINICAL MANIFESTATIONS

– Variable Hypophosphataemia
– Unpredictable Hypokalemia
• Symptoms occur because
Hypomagnesaemia
changes in serum electrolytes
affect the cell membrane Hyponatremia
potential impairing function in
nerve, cardiac, and skeletal Deficiency of thiamine
muscle cells.

Khan LU et al. Gastroenterol Res Pract. 2011;2011. pii: 410971. doi: 10.1155/2011/410971.
40
 Refeeding Syndrome: How to Avoid

• Prevention is the key to successful management

• Three factors appear fundamental:
• Early identification
• At risk individuals, monitoring during refeeding
• Appropriate feeding regimen

Khan LU et al. Gastroenterol Res Pract. 2011;2011. pii: 410971. doi: 10.1155/2011/410971.

41
 Conclusions and Key Takeaways

• Protein is an important macronutrient for nutritional interventions

• Many critically ill patients do not receive the amount of protein
recommended by clinical guidelines
• Sufficient provision of both energy and protein in critically ill patients
is associated with improved clinical outcomes

42
THANK YOU

ACUTE CARE SURGERY, 2020 , BANDUNG 43